Romanian Neurosurgery | Volume XXX | Number 4 | 2016 | October - December

Article

Sciatica due to pelvic hematoma: case report

Umit Kocaman, Muhammet Bahadir Yilmaz, Hakan Yilmaz TURKEY

DOI: 10.1515/romneu-2016-0080

Romanian Neurosurgery (2016) XXX 4: 507 – 511 | 507

DOI: 10.1515/romneu-2016-0080

Sciatica due to pelvic hematoma: case report

Umit Kocaman 1, Muhammet Bahadir Yilmaz 1, Hakan Yilmaz 2

1University of Izmir of Medicine, Department of Neurosurgery, Izmir, TURKEY 2Usak State Hospital, Department of Neurosurgery, Usak, TURKEY

Abstract : Sciatica is defined as in the distribution. The most common reason of sciatica is due to disc . Other causes can be congenital, acquired, infectious, neoplastic, or inflammatory. The is another cause. The pain starts in an insidious manner when the cause of sciatica is an extraspinal tumor. It is intermittent at first but a constant and progressive pain that does not decrease with position or rest gradually develops in all patients. The possibility of an intraabdominal or pelvic mass should always be considered and the relevant tests requested when the cause of the sciatica cannot be explained. We present an 83-year-old male who presented with non-traumatic and non-vascular lumbosacral due to a large hematoma in the left adductor muscle following the use of warfarin sodium. Key words : Lumbosacral plexopathy, pelvic hematoma, sciatica

Introduction origin, and peripheral neuropathies can mimic Sciatica is defined as pain in the sciatica (1,7). distribution of the sciatic nerve. The sciatic The pain increases slowly when the cause nerve consists of components from the L4-S3 of the sciatica is an extraspinal tumor. It is nerve roots. The nerve exits the pelvis from the intermittent at first but a constant and greater sciatic foramen along the posterior progressive pain that does not decrease with part of the thigh. It divides into the tibial and position or rest gradually develops in all main peroneal nerves in the lower third of the patients. The possibility of an intraabdominal thigh (7). or pelvic mass should always be considered The most common cause of sciatica is and the relevant tests requested when the radiculopathy due to lumbar disc hernia. cause of the sciatica cannot be explained (1,7). Other causes can be congenital, acquired, We present an 83-year-old male who presented with non-traumatic and non- infectious, neoplastic, and inflammatory. The vascular lumbosacral plexopathy in the left pyriformis syndrome is another cause. Pain of adductor muscle due to a large hematoma vascular origin, reflected pain not of spinal following the use of warfarin sodium.

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Lumbosacral plexopathy due to a hematoma hematoma in the left iliacus muscle (Figure 2). in the left adductor muscle caused by warfarin The USG revealed a solid mass. The patient use is rare in the literature. Our colleagues was on irregular warfarin and prothrombin should be as careful when injecting substances time was 34 sec. The patient was referred to the in the canal as they are when injecting them general department for the outside the canal during magnetic resonance intraabdominal hematoma. Surgery was not imaging (MRI) investigations. We presented planned due to the additional systemic this case to emphasize the importance of this problems. The patient was hospitalized for precaution. pain control. The pain decreased and became tolerable with tramadol and the hematoma Case report was therefore left to resorb spontaneously. The An 83-year-old man presented with back necessary recommendations for PTZ follow- pain, left leg pain and loss of strength in the left up were obtained from the Hematology leg. The patient said that the pain had been Department and applied. The patient was later continuing for the last 10 days while the loss of discharged and called back for follow-up to the strength had appeared in the last 3 days. The neurosurgery outpatients a week later. pain was resistant to medical treatment and did not resolve with rest. The patient stated that the pain was gradually becoming more severe. The patient was on warfarin sodium due to a heart valve disease but did not have his INR measured regularly. The left Lasegue test was positive at 40 degrees on neurological examination. The left femoral strain test was positive. The left knee extension strength was 4/5 and left ankle dorsiflexion 3/5. The left patella was hypoactive and there was Figure 1 - Low T2 signals in the iliacus muscle in hypoesthesia of the left L3, L4, L5 dermatomes. MRI Left wallex sensitivity was interpreted as positive. Back movements were painful and limited. The patient could only be mobilized with a wheelchair due to the pain. Lumbar MR revealed lumbar degenerative changes and moderate-sized central protrusions at L4-5 and L5-S1. The sections also revealed marked atrophy of the left psoas muscle and low T2 signals in the iliacus muscle (Figure 1). Pelvic computerized tomography (CT) was therefore Figure 2 - Hematoma in the left iliacus muscle in requested and the images were consistent with pelvic CT

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Discussion sciatica etiology, especially when atypical Sciatica is defined as pain in the sciatic neurological symptoms are present (1). nerve distribution. The sciatic nerve consists Melikoğlu et al reported a 50-year-old of components from the L4-S3 nerve roots. woman with trauma to the thorax, abdomen The nerve exits the pelvis from the greater and left hip. Severe left sciatica and left foot sciatic foramen along the posterior part of the drop developed approximately three weeks thigh. It divides into the tibial and main after the trauma. Magnetic resonance imaging peroneal nerves in the lower third of the thigh showed a large hematoma area next to the (7). lumbosacral plexus and CT angiography The most common cause of sciatica is revealed a left internal iliac artery aneurysm. radiculopathy due to lumbar disc hernia. The pain resolved immediately with surgical Other causes can be congenital, acquired, treatment while the foot drop only recovered infectious, neoplastic, and inflammatory. The partially (6). This case emphasizes the pyriformis syndrome is another cause. Pain of importance of considering pseudoaneurysm vascular origin, reflected pain not of spinal in cases with sciatica or neurological deficits origin, and peripheral neuropathies can mimic that develop following incidental trauma or in sciatica (1,7). an iatrogenic manner. The pain starts in an insidious manner There are many causes of sciatica. when the cause of sciatica is an extraspinal Intraabdominal masses may cause sciatica tumor. It is intermittent at first but a constant through their effect on the lumbosacral plaxus and progressive pain that does not decrease following local invasion or distant metastases. with position or rest gradually develops in all Lumbosacral plexopathy usually develops due patients (7). The possibility of an to a compressive effect of the tumor. Invasion intraabdominal or pelvic mass should always is a less frequent mechanism (5). Lin et al have be considered and the relevant tests requested reported a 67-year-old female who presented when the cause of the sciatica cannot be with neurogenic claudication, and explained. left foot drop that had been increasing for the Bushby et al have reported lumbosacral last three months. This was accompanied by plexopathy and sciatica due to a ruptured main increasing abdominal distension. Imaging iliac artery aneurysm. Their patient presented studies revealed a large pelvic mass with back pain and sciatica, loss of sensation, compressing the left lumbosacral plexus. loss of strength and numbness that included Direct plexus invasion was not found on the L4-S1 roots. CT imaging revealed a large imaging or with observation during surgery. hematoma in the left side of the pelvis due to Bilateral ovarian borderline mucinous cystic an 8 cm main iliac artery aneurysm. One must tumor accompanied by be careful about pelvic and intraabdominal pseudomyxomaperitonei was found and space-occupying lesions while searching for surgically removed, leading to a dramatic recovery in the sciatica (5).

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Ladha et al mention a different spread examination can again suggest lumbosacral mechanism for the lumbosacral plexopathy plexopathy. The most important signs caused by prostate . They report two indicating lumbar plexopathy are sciatica lumbosacral plexopathy and sciatica cases that unexplained by the spinal column pathology developed without any pelvic of extraprostatic on lumbar MR together with the examination spread. They state that the possible mechanism findings. It is important to thoroughly evaluate here is direct perineural spread from the the adjacent spinal canal in addition to the prostatic nerves to the lumbosacral plexus. spinal column on MR images. Radiologists This could be a rare potential spread should be consulted regarding this matter and mechanism of cancer (4). the images should be evaluated together with Dyck et al have divided lumbosacral the radiology report. Abdominal tomography plexopathy into two groups as diabetic and can be used as an additional test if necessary. non-diabetic using a different approach. They state that the cause is ischemic injury due to Conclusion microvascular damage in many cases thought The history, physical examination and to be idiopathic. They also emphasize the radiology play a very important role in the importance of immunotherapy although the evaluation of the patient with sciatica. The evidence is currently inadequate (2). most important signs indicating lumbar Ko et al have described some features of plexopathy are sciatica unexplained by the lumbosacral plexopathies. They state that non- spinal column pathology on lumbar MR traumatic lumbosacral plexopathies are due to together with the examination findings. It is a neoplasm in 59.3%, radiotherapy in 22.2%, important to thoroughly evaluate the adjacent neurological amyotrophy in 7.4%, and a psoas spinal canal in addition to the spinal column abscess in 3.7%. The idiopathic cases make up on MR images. Radiologists should be 7.4%. Pain is the presenting symptom in 82.2 consulted regarding this matter and the of the neoplastic cases (3). images should be evaluated together with the Lumbosacral plexopathy with non- radiology report. traumatic, non-vascular spontaneous retroperitoneal hematoma due only to Written informed consent of the patient was warfarin use has been reported very rarely. obtained. This hematoma was also present in the lumbar MR images of our patient. A careful history Correspondence should be obtained when evaluating sciatica. Hakan YILMAZ, Usak State Hospital, Department Resistance to medical treatment, progressive of Neurosurgery, Usak, Turkey. e-mail: [email protected] increase of the pain, no recovery with position Tel: +90 5066211829 or rest could indicate lumbosacral plexopathy.

Atypical neurological deficits and atypical distribution of the pain on neurological

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